Documentation

Only 24 of the 101 patients who had a serious illness conversation received a dedicated SIC clinical note. The structured SIC documentation template was embedded in the electronic health record and mirrored the Guide's sequence and content. Most clinicians preferred their usual documentation methods because the template disrupted workflow and duplicated data entry. Fragmented documentation caused avoidable repetition when an oncologist was unaware that a cardiologist had already conducted an SIC.